Difficult Conversations

Medicine can be full of difficult conversations.  

If we're lucky we get some guidance with these during our training years, and I believe there are movements afoot in training programs across the country to help clinicians learn how to manage these better, but there's no getting around the fact that they're hard.  Hard for patients, hard for doctors.  Everyone wants to be sure all the right things get said, ideally with clarity and grace.

Before I walk into a patient's room to have one of these difficult conversations, I try to have a mini-conference with the patient's nurse and, if possible, other doctors involved in the patient's care.  I still find that I ask myself the same questions I used to ask when I was a student. 

What am I going to say?  

How can I possibly say that?  

What can I do to make this easier for them?  For me?  

Will they understand everything they need to?  Will I?  

How can I make sure they know I'm listening, too?

What's easier now, a few years down the pike, is that I've had more experience from which to draw answers and examples.  I'm more confident about what I know and what I think, and pretty comfortable admitting what I don't know or am not so sure about (although the latter was already true back when I was in school).  But the conversation itself - coming up with the words, the actual words - isn't that much easier now.  It's still hard to talk about the important stuff - life, death, love, sex, fear, hatred, secrets, pain - face to face.

I find that difficult conversations revolve around one or more of the following underlying themes:

• "You suck."
  
• "You're wrong."
  
• "I'm wrong."
  
• "I can't..."
• "You can't..."
• "I don't want to..."
  
• "I want/need you to..."
  
• "We've got trouble."
  

With patients, some of the most common difficult conversations are along the lines of "We've got trouble."  Sometimes it's relatively small trouble:  I have to postpone your surgery by a few hours because of the chewing gum you were chewing when you walked in.  Sometimes it's a little more serious: I have to cancel this entirely because the monitors suddenly show you in a bad heart rhythm.  Sometimes the trouble is huge:  You're probably going to die.   

One type of conversation that can be particularly challenging is the negotiation to suspend a DNR/DNI order when a patient needs to be intubated for surgery.  I always try to let patients and their families express what it is that they really don't want - usually it's a long, drawn-out dying process in the presence of life-sustaining machines.  Then we go item by item down a list of possible interventions during the resuscitation process that providing anesthesia requires in all patients to some degree, in some patients to a greater degree:  drug intervention, arterial and central lines, CPR, defibrillation, open cardiac massage, blood transfusion, temporary assisted ventilation in the recovery period.  So far I've been able to reach a consensus with families - a detailed plan that clarifies what they give me permission to provide while I'm in the operating room with their loved one.

Another type of difficult conversation is the one informing a patient that for safety reasons, he or she needs to be intubated while still awake.  I guess this would fall into the "You can't" or "I can't" category ("For your own safety, I can't knock you out before putting the breathing tube in") or the "I want/need you to" category ("I need you to let me place this instrument into your wind pipe with you not entirely asleep so I can make sure we can secure your airway").  

I find this one even tougher than the preceding example.  At least in a DNR suspension there's some room for negotiation; for a really tough airway, though, there isn't much wiggle-room at all.  Even with fancy video laryngoscopes that have come into clinical use in the last few years, we still occasionally encounter those scary, impossible airways that make your blood run cold.  I once worked with a surgeon who transferred a patient to a tertiary care facility because he was nervous about the patient's airway in the middle of the night in a small hospital with only a skeleton crew.  We heard later that the awake intubation at the tertiary care place took an hour to do.  It's serious business.

Med school and residency train us to know what to do and when.  As for what to say and how (or how not) to say it, well...I suspect most of us get the bulk of training where we learn most of our communication skills:  from our relationships, mostly outside the classroom.  For most of us that means the training is ongoing, and we're all going to be works in progress for a very long time.  May all our difficult conversations be imbued with attentiveness and a gentle spirit!